REFERENCES	(Give below the names of three persons not related to you, whom you have know at least one year)
Name		Phone	Business	Years Known
AUTHORIZATION
"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.   I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.   I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.   This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws."
Date___________________________________		Signature________________________________________________________
Interviewed By_______________________________________			Date___________________________________
Do Not Write Below This Line
Remarks
Neatness		Character
Personality			Ability
Hired	For Dept.	Position	Will Report	Salary Wages
Approved:	1._________________	2._________________	3.________________	___________
	Employment Manager	Department Head	General Manager	Date